Provider Demographics
NPI:1467502930
Name:COOK, BRADY L (MD)
Entity Type:Individual
Prefix:DR
First Name:BRADY
Middle Name:L
Last Name:COOK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:2985 CORTEZ AVE
Mailing Address - Street 2:STE 200
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-7554
Mailing Address - Country:US
Mailing Address - Phone:208-535-4300
Mailing Address - Fax:208-535-4315
Practice Address - Street 1:3200 CHANNING WAY
Practice Address - Street 2:STE 205
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-7546
Practice Address - Country:US
Practice Address - Phone:208-535-4300
Practice Address - Fax:208-535-4315
Is Sole Proprietor?:No
Enumeration Date:2007-01-10
Last Update Date:2017-03-21
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IDM9386207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID807318100Medicaid
ID1131378Medicare ID - Type Unspecified
IDI38585Medicare UPIN